People, myself included up until about a year ago, tend to focus primarily on the medical causes of various conditions and illnesses. While an understanding of the physical cause informs the type of care or treatment a patient receives, it does little to address the underlying issues that likely resulted in the onset of illness. A question often not considered, but that I would argue is more important than that of “What is the medical cause of a given condition?” is “What causes the medical cause of a particular condition?” These “causes of causes” are formally referred to as social determinants of health (SDH).
The Commission on Social Determinants of Health (CSDH) was established in March of 2005 by the World Health Organization (WHO). It was tasked with compiling and reviewing information on how to recognize the SDH that give rise to health inequity and mitigate said inequity, recommendations for which were outlined in a 2008 report titled “Closing the Gap in a Generation”. This group also facilitated partnerships with countries that were committed to tackling health inequity and engaged policymakers in discussions that helped promote SDH agendas in the political arena.
At the 2011 World Conference on Social Determinants of Health, the Rio Political Declaration on Social Determinants of Health was written. It emphasized that SDH play a critical role in understanding health disparities and called for the implementation of policies that would fight health inequity all over the world.
What are Social Determinants of Health (SDH)?
SDH are a subset of a larger category known as determinants of health, where other subsets include biological and genetic factors, governmental policies, and availability of healthcare.
The WHO defines SDH as the “conditions in which people are born, grow, work, live, and age”, and goes on to state that “these circumstances are shaped by the distribution of money, power and resources at global, national, and local levels…[and] are mostly responsible for health inequities”. The WHO has identified ten SDH:
- The Social Gradient/Ladder: This is the strongest predictor of wellbeing, where those who are at the top of the gradient possess the most power and resources, while those at the bottom tend to have at least twice the risk of serious illness or premature death as compared to those at the top. This gradient can be measured by income, education, place of residence, occupation, etc.
- Stress
- Early Life
- Social Exclusion
- Work
- Unemployment
- Social Support
- Addiction
- Food
- Transport
This list is by no means comprehensive, and can be expanded to include crime rates and/or exposure to violent behavior, access to a toxin-free environment, and access to recreational activities, but the aforementioned determinants are the most widely accepted.
How do Social Determinants of Health Cause Illness?
In light of the COVID-19 pandemic, it has become increasingly evident that SDH play a role in patient health and experiences in our healthcare system. Let’s take two sample patients who have contracted COVID-19 and walk through how various SDH have and/or will influence their health outcomes.
Let’s imagine Patient A and Patient B are both high school graduates, but Patient A attended a public school in the Bronx, while Patient B attended a private school in Manhattan. Patient A received a lower quality of education than Patient B because public schools are funded by income and property taxes; lower-income areas, such as the Bronx, collect fewer taxes, so less funding is allocated to education. A below average education made it difficult for Patient A to excel in his classes and college entrance exams, and his family was not able to afford higher education for him. As such, only Patient B obtained a higher education because she received an above average education, excelled in her courses and college entrance exams, and her family was able to afford it (e.g. MBA).
Patient A works as a retail assistant, while Patient B is the CEO of a mid-sized retail chain. While Patient B is afforded the luxury of working from home during the pandemic, Patient A is considered an essential worker and must continue going into work daily, which requires him to take public transportation because he does not have a car. The difference in income and area of residence also affects the type of healthcare that Patients A and B are eligible for, where Patient A may not receive the same quality of care or have immediate access to the same facilities that Patient B may have.
In the situation that both Patient A and B contract COVID-19, it would appear, based on each of their individual circumstances, that Patient B is better equipped to afford and receive the care she requires compared to Patient A. Patient A is also more likely to contract COVID-19 because he is an essential worker and must take public transportation to work each day. It can be seen that different SDH, such as social gradient, work, and transportation build off of and coalesce with one another to create a comprehensive picture of the factors that influence a patient’s health outcomes.
What’s Next?
A study titled “Variation in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health Case, 2000-09” was published in 2016 by Bradley et. al. It revealed that states that devote more resources to social services, which reduce the negative effects of some of the aforementioned SDH, have exhibited a substantial improvement in health outcomes compared to states that do not.
The results of this study, and similar studies, have encouraged healthcare professionals to partner with community-based organizations (CBOs) to help impoverished areas gain access to adequate housing, nutritious food, education, job training, transportation, etc. Ideally, CBO networks would be established at the local, state, and multi-state levels and serve as a point of accountability for various healthcare systems in a particular region.
Here are a few CBOs that already have inspiring initiatives underway:
- Healthy Neighborhoods Healthy Families (Nationwide Children’s Hospital in Columbus, Ohio)
- Nashville International Center for Empowerment (Nashville, Tennessee)
- Siloam Health (Nashville, Tennessee)
- PRAPARE: Assessing Social Determinants of Health in Your Patient Population
It is imperative, if we want to reduce health inequity, that we begin to place a heavier emphasis on SDH and the impact that they have on patient experiences and health outcomes. We must also recognize that even as individuals, we have the ability to effect change on a much larger scale by getting involved with CBOs and advocating for a more informed and empathetic generation of healthcare professionals, economists, and policymakers.
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